Unrestricted access to tenofovir, lamivudine, and dolutegravir as pre-exposure or post-exposure prophylaxis in community settings
Authors: Lynda Stranix-Chibanda, Tsungai Mhembere
Journal: The Lancet Global Health (2023)

In The Lancet Global Health, Andrew Philips and colleagues1Philips AN Bansi-Matharu L Shahmanesh M et al.Potential cost-effectiveness of community availability of tenofovir, lamivudine, and dolutegravir for HIV prevention and treatment in east, central, southern, and west Africa: a modelling analysis.Lancet Glob Health. 2023; 11: e1648-e1657Google Scholar present a case for making tenofovir, lamivudine, and dolutegravir (TLD) widely and freely available in communities without prescription to reduce HIV incidence by enabling ready access to post-exposure prophylaxis (PEP). Their modelling suggests that this widely and freely available TLD (named community TLD) would be cost-effective across Africa. They propose that there would be a population-level benefit via bypassing structural and socioecological barriers to access. The authors hypothesise that community TLD would increase protection from infection from condomless sex in people who were HIV negative when used as PEP or pre-exposure prophylaxis (PrEP), and also increase antiretroviral therapy coverage for people living with HIV. In contrast to the clinician-led prescribing of PEP and PrEP, community TLD transfers the decision to the individual having condomless sex, with PEP and PrEP uptake being driven by their perceived risk of acquiring HIV. Possible negative effects include TLD use without formal engagement with the health-care system, although people using community TLD in the proposed model would have simultaneous free access to condoms and HIV self-testing kits, and be encouraged to present to the nearest health-care facility for ongoing care. Although the absence of HIV testing and monitoring could be detrimental for an individual, the model predicts an encouraging population-level effect at 20 years with reduced HIV incidence, prevalence, and deaths. Although there is substantial uncertainty, and the numerous assumptions upon which this model is based could be overly optimistic, the community TLD model deserves further examination. Community TLD prioritises people who require HIV services but are not yet accessing them—namely, the focal population of the Global AIDS Strategy 2021–26.2UNAIDSGlobal AIDS Strategy 2021–2026. End inequalities. End AIDS.https://www.unaids.org/sites/default/files/media_asset/global-AIDS-strategy-2021-2026_en.pdfDate accessed: August 10, 2023Google Scholar This strategy seeks to end AIDS as a public health threat by 2030 through equitable and equal access to effective HIV solutions, and highlights the need to break down societal and legal barriers for underserved groups. Despite notable efforts to provide person-centred HIV prevention and treatment options, health-care systems worldwide are overstretched, and most countries are not on track to end AIDS by 2030. The reality of finite resources has encouraged reproducible, scalable, and wide-ranging interventions against HIV, distant from individual-based care. Community TLD might shift the focus to groups that have disproportionately high HIV acquisition and transmission and extend the utility of currently available drugs before long-acting treatment and prevention becomes available. Adopting a destigmatising population-level intervention such as community TLD, if acceptable and feasible, could be the impetus needed to achieve the three zeros: zero new HIV infections, zero AIDS-related deaths, and zero HIV-related discrimination.2UNAIDSGlobal AIDS Strategy 2021–2026. End inequalities. End AIDS.https://www.unaids.org/sites/default/files/media_asset/global-AIDS-strategy-2021-2026_en.pdfDate accessed: August 10, 2023Google Scholar HIV care extends beyond taking medication, and HIV is not the only aspect of health affecting individuals having condomless sex. It is not clear whether community TLD would alter health-seeking behaviour for other sexually transmitted infections, contraception, and associated mental health outcomes. Of particular interest is how people using community TLD would interact with HIV self-testing kits, and whether the approach would create new opportunities for expanding access to combination self-testing kits for HIV and other sexually transmitted infections. Ultimately, the implementation approach for community TLD should facilitate users to know their HIV status and promote prompt linkage with integrated HIV treatment and care that optimises holistic health. One concern is that community TLD could be diverted from its intended purpose if made freely available in communities where resources are low. Insecticide-treated bednets, for instance, were often repurposed for catching fish after their distribution as part of malaria control campaigns,3Larsen DA Makaure J Ryan SJ et al.Implications of insecticide-treated mosquito net fishing in lower income countries.Environ Health Perspect. 2021; 129015001Crossref Scopus (7) Google Scholar where some families valued the immediate benefit of supplemental protein more than an intangible threat of disease. We found no reported alternative uses for TLD, although there are surveys and qualitative data describing ART being diverted for recreational drug use, particularly efavirenz-containing formulations being ground and mixed in the street drug concoctions known in southern Africa as whoonga or nyaope.4Rough K Dietrich J Essien T et al.Whoonga and the abuse and diversion of antiretrovirals in Soweto, South Africa.AIDS Behav. 2014; 18: 1378-1380Crossref PubMed Scopus (29) Google Scholar, 5Kuo C Giovenco D DeAtley T et al.Recreational use of HIV antiretroviral medication and implications for HIV pre-exposure prophylaxis and treatment.AIDS Behav. 2020; 24: 2650-2655Crossref Scopus (8) Google Scholar Antiretrovirals have also been used by farmers to promote rapid growth and control diseases in pigs and broiler hens.6Ndoboli D Nganga F Lukuyu B et al.The misuse of antiretrovirals to boost pig and poultry productivity in Uganda and potential implications for public health.Int J One Health. 2021; 7: 88-95Crossref Scopus (1) Google Scholar We consider the misuse of community TLD to be a distinct possibility, given a declining HIV prevalence and harsh economic climate across the region. Uptake and adherence to community TLD as PEP are unpredictable, and the likelihood of subsequent linkage with formal health services is unknown. Although we understand the rationale for performing this cost-effectiveness analysis so early in the development of this complex intervention, we stress the urgency of meaningful dialogue with communities to better understand the needs and motivation of people who use PEP and PrEP, in all their diversity. Respectful community consultations should formulate the proof-of-concept pilot projects, driving the communication strategy and implementation approach, to have the best shot at community TLD becoming a transformative and sustainable HIV response. We declare no competing interests. Potential cost-effectiveness of community availability of tenofovir, lamivudine, and dolutegravir for HIV prevention and treatment in east, central, southern, and west Africa: a modelling analysisThe introduction of community TLD, enabling greater PEP access, is a promising approach to consider further in pilot implementation projects. Full-Text PDF Open Access